Provider Demographics
NPI:1568913713
Name:SLACK, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:SLACK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 N 2ND ST
Mailing Address - Street 2:
Mailing Address - City:ATCHISON
Mailing Address - State:KS
Mailing Address - Zip Code:66002-1402
Mailing Address - Country:US
Mailing Address - Phone:913-360-7541
Mailing Address - Fax:913-367-2564
Practice Address - Street 1:1020 N 2ND ST
Practice Address - Street 2:
Practice Address - City:ATCHISON
Practice Address - State:KS
Practice Address - Zip Code:66002-1402
Practice Address - Country:US
Practice Address - Phone:913-360-7541
Practice Address - Fax:913-367-2564
Is Sole Proprietor?:No
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-002532255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer